SBA Form 994H Default Report Claim for Reimbursement

OMB No: 3245-0007
EXP. DATE:
U.S. Small Business Administration
Surety Bond Guarantee Program

DEFAULT REPORT, CLAIM FOR REIMBURSEMENT,
AND REPORT OF RECOVERIES
Any intentionally false statement or willful misrepresentation in connection with a claim for payment pursuant to a Guarantee Agreement is a violation
of Federal law, subject to criminal and civil prosecution under 18 USC Sections 287, 371, 1001, 15 USC Section 645 and 31 USC Section 3729 carrying
possible fines and/or imprisonment.

GENERAL INSTRUCTIONS:
1. The Surety may use this form to file an initial or updated Default Status Report by completing sections A, B, C, and H. If a different format is used,
all of the requested information must be provided.
2. The Surety must use this form to:
File a Claim for Reimbursement; complete sections: A, C, E, F, G, H
Report Recoveries, complete sections: A, C, F, G, H
Please type or print legibly. The surety company must print, sign, and mail to U.S. Small Business Administration, Office of Surety Guarantees, 409 3rd St., SW,
Washington, DC, 20416

A. SBG IDENTIFICATION SUMMARY
SBG NUMBER: ___________________________________________
SURETY ALPHA CODE: ___________________________________
BOND NUMBER: _________________________________________
CLAIM NUMBER: ________________________________________
DEFAULT STATUS CODE:
 01=Active
 02=Closed-No Loss
 03=Closed-Subrogation
 04=Closed-Final
 05=Closed Settled

BOND TYPE:
 Payment
 Performance
 Bid

DEFAULT REASON CODE: ________ (From reverse)

CONTRACTOR’S NAME: ______________________________________
_____________________________________________________________
990 DATE: / /
(See reverse) CONTRACT AMOUNT $__________
OBLIGEE: ___________________________________________________
PROJECT: ___________________________________________________
DEFAULT DATE:
/ /
LAST STATUS REPORT:

/

/

CLOSE DATE: (SBA USE ONLY)

/

/

____ NO CHANGE FROM PREVIOUS REPORT
____ STATUS UPDATE INCLUDED: (Describe below, current status and
default completion plans.)

SBA’s RESERVE AMOUNT:

$ ___________________________

SURETY RESERVE AMOUNT: $________________________________

B. SUBROGATION ACTIVITY (Explain in Section C., below, or attach a separate sheet if, necessary.)
____ Litigation pending
____ Settled for $_______________
____ Payments being made

____ None – Bankrupt/Defunct

____ No change from last report
____ Approval requested to Close Final
____ Firm Collateral Held $_______________

Other anticipated recovery from salvage, indemnities, etc. $______________________________________
C. EXPLANATIONS, COMMENTS, ADMINISTRATIVE ACTIONS (Attach additional sheet if warranted.

(SBA USE ONLY)

D. SBA/SBG CLAIM PAYMENT RECOMMENDATION, REVIEW, APPROVAL, AND AMOUNT OF CLAIM APPROVED
THIS REQUEST IS HEREBY APPROVED FOR PAYMENT IN ACCORDANCE WITH SBA REGULATIONS.
AMOUNT REQUESTED $________________ AMOUNT APPROVED $________________ EFFECTIVE DATE (Date SBA received)
RECOMMENDED BY
(Signature/Title/Date)

REVIEWER
(Initials/Date)

SBA Form 994H (2/16) Previous Editions are Obsolete

2ND REVIEWER
(Initials/Date)

/

/

APPROVING OFFICIAL
(Signature/Title/Date)

See instructions on reverse

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E.

ITEMIZATION OF SURETY LOSS (Loss Class Codes: L=Loss; E=Expense; TA=Trust Account Deposit)
List all loss items as well as funds deposited to a Trust Account. (See reverse)
DRAFT
DRAFT
DATE
NUMBER
PAYEE

TOTAL

F.

LOSS
CLASS

AMOUNT

$ _____________________________

ITEMIZED SURETY RECOVERY See Instructions. (Recovery Class Codes: I=Indemnity; C=Contract Funds)
DATE
SOURCE
RECOVERED
AMOUNT

TOTAL

RECOVERY
CLASS

$ ______________________________

G. SUMMARY OF CLAIM FOR REIMBURSEMENT
Total of Loss Disbursements (Itemized Above)

$ _____________________

Total of Loss Disbursements Previously Reported

$ _____________________

TOTAL LOSS DISBURSEMENTS
Recovery (Itemized Above)

$ _____________________
$ _____________________

Recovery Previously Reported

_____________________

Undisbursed Trust Account Balance (See reverse)

_____________________

TOTAL OFFSETS

$ ( ___________________ )

Surety Net Loss (Total Loss Disbursements Less Total Offsets)

$ _____________________

Less Deductible Amount (See reverse)

( ____________________ )

SBA (_____ %) Share of Surety’s Reimbursable Loss

____________________

Less Prior Total SBA Payments

( ____________________ )

TOTAL DUE AND REQUESTED BY SURETY _____ OR TOTAL DUE AND SUBMITTED TO SBA _____

$ _____________________

H. CERTIFICATION

I, the undersigned being duly designated, hereby certify that this default report and/or itemization and summary of payments and
recoveries received upon bonds issued in conjunction with the U.S. Small Business Administration’s Surety Bond Guarantee Program is
true and correct to the best my knowledge, information and belief. I further certify that all payments made and recoveries received are
substantiated by payroll sheets, copies of Surety’s drafts, claimants invoices, assignments and releases (where applicable), recovery
instruments, etc., and that such substantiating documents are retained in this office, our agent’s office, or in the office of our claim account
trustee. I further certify that the Surety has complied with all SBA Surety Bond Guarantee Program regulations in 13 CFR Part 115 and all
SBA program requirements.
NAME OF SURETY

(Area Code/Phone No.)

SBA Form 994H (2/16) Previous Editions are Obsolete

SURETY CERTIFYING OFFICIAL’S SIGNATURE, TITLE, AND DATE

See instructions on reverse

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INSTRUCTIONS AND CLARIFICATION
OF SELECTED FORM 994H ITEMS
General
1.

This form may be used to report the default of an SBG contractor, as well as for periodic status reporting in accordance with the terms
of SBA’s Surety Bond Guarantee Agreement and SBA regulations in 13 CFR Part 115. If a different format is used, all information
requested on 994H Form must be provided.

2.

A separate SBA Form 994H must be used for each bond in default/claim status. An additional sheet/letter may be attached for more
detailed reporting.

3.

If this is an initial default/claim notice:
Provide a detailed report including the percentage of completion, remaining contract funds, methods of selecting completion
contractor, description of how claim situation arose, present condition, surety’s plans for resolution and salvage, anticipated loss.

Specific
Section A.

1)
2)
3)

“SBG Number” – enter the full 16-digit number.
“990 Date” is the date SBA Form 990, “Surety Bond Guarantee Agreement,” was signed by SBA Official.
DEFAULT REASON CODES:

CODE
1. Underbidding
2. Weather/natural disasters
3. Shortage in critical materials/
Delays in receiving same
4. Alleged embezzlement
5. Financial mismanagement
6. Incompetence/poor workmanship
7. Union strike/labor trouble
8. Illness or death of key employee
9. Walked off job
10. Dispute with obligee
11. Possible fraudulent operation
on part of principal
12. Despondency
13. Co-mingling of funds

CODE
14. General’s subcontractor in default
15. Sub’s General in default
16. Possible sub-busting on part of general
17. IRS lien
18. Sub’s General behind Schedule
19. Unforeseen physical obstacle
20. Shortage of labor
21. Principal fails to appear at job site
to begin work
22. Fire damage
23. Material man lien
24. Labor lien
25. Principal failed to sign contract
26. Surety did not issue final bond
27. Other

Section E.

1)

List all loss items as well as funds deposited to a trust account. A separate accounting must accompany any request for
reimbursement of loss incurred via a trust account. Such accounting must provide the source of all deposits to the account, and
the disposition of all funds from the account (by date, draft number, payee and amount). Any balance remaining in the account
or any amounts not accounted for as expenditures comprise the trust account balance and are to be included in Section G. as
“Undisbursed Trust Account Balance.”

Section F.

1)

List all recovery items received by the Surety. Also, list as recovery, all trust account remaining balances returned by the trustee.

Section G.

1)

The “Undisbursed Trust Account Balance” is reduced to zero when the remaining balances are returned by the trustee. See
instructions for Section E., above.
The “Total of Loss Disbursements” is the total amount from Section E., “Itemization of Surety Loss.”
The “TOTAL LOSS DISBURSEMENTS” is the combined total of loss disbursements itemized and previously reported.
The “Deductible Amount” is 80% of the Premium amount up to $500 for Guarantee Agreements written between April 21, 1976
and November 28, 1988.

2)
3)
4)

PLEASE NOTE: The estimated burden for completing this form is approximately 20 minutes per response. You are not required to respond to any
collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business
Administration, Chief, AIB, 409 3rd St., SW, Washington DC 20416 and Desk Officer for the Small Business Administration, Office of Management and
Budget, New Executive Office Building, Room 10202 Washington, DC 20503. OMB Approval (3245-0007) PLEASE DO NOT SEND FORMS TO
OMB.

SBA Form 994H (2/16) Previous Editions are Obsolete

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